Interal-arm blood pressure difference with computer-programmed blood pressure measurement: difference between the first reading and the average of the second and the third readings.

Background: Hypertension (HTN) incidence and progression are monitored by regular blood pressure (BP) measurement; one of the most ignored components of regular check-up is the measurement of inter-arm difference (IAD) in BP. Aims and Objectives: The objective of this study was to estimate the prevalence of IAD in BP among offspring of hypertensive parents compared to normotensive parents. Materials and Methods: This cross-sectional study was conducted on 100 male students at Osmania Medical College, Hyderabad, Telangana for a period of 6 months. After IEC clearance, the subjects were divided into two groups, 50 students in each group: Group I had offspring with hypertensive parents and Group II had offspring with normotensive parents. Age, height, weight, and body mass index (BMI) were recorded. IAD was calculated as the difference between BP (Systolic BP [SBP] and diastolic BP [DBP]) in the right arm and left arm. Subjects with a history of structural, functional cardiovascular disease disorders, endocrine disorders, Diabetes mellitus, and addictions such as smoking and alcohol were excluded from the study. Data were statistically analyzed using Microsoft Excel software. Results: Among 100 subjects, Group I and II IAD in SBP was 8.68±6.02 and 5.00±3.24 (P<0.0002), respectively, and Group I and II IAD in DBP was 5.12±4.48 4.79±3.56 (P<0.7117), respectively. BMI of the two groups is almost within the similar range (23.44±4.04, 22.098±3.15, respectively) and not statistically significant (P=0.0694), a positive correlation of 0.12, 011 was found between BMI, systolic IAD,and diastolic IAD, respectively. Conclusion: The above results show a significant association between IAD in systolic BP and family history of HTN.

ObjectiveWe investigated the association of ankle-brachial blood pressure index (ABI), interarm blood pressure (BP) difference and interankle BP difference, obtained by simultaneous four-limb BP measurement, with history of stroke in a Chinese adult population.MethodsThis cross-sectional study included 1485 participants aged ≥35 years in the framework of the China Hypertension Survey. We performed simultaneous four-limb BP measurement using oscillometric devices with the participants in the supine position and calculated ABI and interarm/interankle BP differences between the 4 limbs. Logistic regression analysis was used to estimate the association of these BP parameters and other factors with a history of stroke.ResultsIn univariate analyses, participants with ABI <0.9, interarm BP difference ≥15 mmHg, and interankle BP difference ≥10 mmHg had a higher prevalence of stroke than those without (p < 0.0001, p = 0.0152, p = 0.002, respectively). Multiple logistic regression analyses suggested, ABI <0.9 was independently associated with a history of stroke after adjustment for interarm BP difference ≥15 mmHg, interankle BP difference ≥10 mmHg, and traditional risk factors for stroke (p = 0.001). An interankle BP difference ≥10 mmHg was associated with prior stroke after the two variables of hypertension and ABI were removed from the logistic regression model (p = 0.0142). Net reclassification improvement analysis showed that inclusion of interankle BP difference ≥10 mmHg to the independent risk factors (age, family history of stroke, hypertension, and ABI) improved net reclassification by 11.92%.ConclusionABI <0.9 is an independent risk factor for stroke prevalence in Chinese adults and it just detected a small propotion of paticipants. The addition of interankle BP difference ≥10 mmHg to the independent risk factors for stroke may improve the prediction of stroke.

We read the article “Inter-Arm Blood Pressure Difference in Hospitalized Elderly Patients Is Not Associated With Excess Mortality” written by Weiss and colleagues1 with great interest. They concluded that a more than 10 mm Hg inter-arm BP difference (IAD) for both systolic and diastolic blood pressure (BP) was not associated with mortality in hospitalized elderly individuals. Thanks to the authors for their contributions. But, it is well-known that IAD is associated with peripheral vascular disease and associated with cardiovascular mortality, especially in elderly patients with hypertension, diabetes mellitus, and ischemic heart disease.2 The measurement of BP in both arms and legs is very important in case of vascular disease such as peripheral vascular disease, aortic coarctation, and subclavian artery disease.2 The BP differences in both arms at the initial evaluation may lead to underdiagnosis of hypertension; therefore, it is recommended to not only measure BP in one arm.3 The impact of IAD during BP measurements has been a subject of extensive research in recent years.4, 5 There may be a relationship between IAD and increased risk of cardiovascular morbidity in older patients.5 In the present study, the characteristics of vascular disease in the patients were not emphasized. We did not know about the subclavian stenosis of the patients. It would be useful to perform Doppler ultrasonography of the upper extremities to identify the vascular disease and actual IAD of these elderly patients. The atherosclerosis of the subclavian arteries may predict the total arterial system atherosclerosis. Therefore, this condition may be related with morbidity and mortality, especially in very elderly patients. The results of studies about the effects of IAD in very elderly patients might be controversial. Currently, coronary risk factors, eg, hypertension, obesity, and diabetes, are increasing in the elderly population.6 Higher systolic and diastolic BP may be one of the features of excessive cardiovascular risk not only for elderly patients but also younger patient.7, 8 Additionally, the measurement of BP must be very sensitive. While some centers can do it automatically, measurements are usually performed manually. Twenty-four–hour ambulatory BP monitoring is the best way of excluding white-coat hypertension in laboring patients with higher BP measurements in the doctor's office, even if elderly.9 There are some reports about IAD and increased mortality in elderly patients. It is expected that very old patients likely have a higher prevalence of atherosclerosis. IAD >10 mm Hg has been found to predict cardiovascular morbidity and mortality, especially in patients with diabetes, stroke, and hypertension.10 In conclusion, the subject is very important and we need further studies to better evaluate and understand BP measurements in both arms to exclude some cases of vascular disease and detect IAD in elderly and young patients. The very elderly with atherosclerotic vascular disease may have more IAD and may have increased cardiovascular morbidity and mortality. There is no conflict of interests.

Cardiovascular disease is a notable cause of death globally. When undetected, varying measurements of BP between arms can lead to inaccuracies in the interpretation and management of blood pressure consequently putting individuals in an avoidable risk through sub-optimal blood pressure control. The aim of the study was to determine the difference in blood pressure between the arms and its association to cardiovascular risk in young adults at Ellisras. A total of 624 young adults aged 18 to 29 years old participated in the study. Blood pressure measurements and blood analysis were done according to standard procedures. Multivariate logistic regression was used to determine the association between interarm blood pressure and cardiovascular risk factors. There was significant (p ≤ 0.05) mean difference of diastolic blood pressure of the &lt;10 mmHg and ≥ 10 mmHg groups. There was a positive significant association between systolic inter arm blood pressure difference and hypertension (B = 5.331; 95%CI = 12.260–23.183; P = 0.026) while no significant association was found between diastolic blood pressure and interarm diastolic differences in diastolic blood pressure (B = 1.081; 95%CI = 1.032–1.131; P = 0.920). The current study showed positive associations between inter arm differences and a few cardiovascular risk factors including BMI and gender. Detection of an interarm BP difference should motivate the need for a thorough cardiovascular/health assessment.

Objective: Inter-arm blood pressure differences (IADs) are known to be associated with adverse cardiovascular outcomes. We evaluated the distribution of IADs in a large cohort of apparently healthy people and the association of IADs with brachial-ankle pulse wave velocity (baPWV) and coronary artery calcium (CAC). Methods: Blood pressure was measured in both arms of 117,407 people who participated in the Kangbuk Samsung Health Study. IAD was defined as the absolute difference in systolic blood pressure in both arms and was confirmed by measuring the baPWV using an automatic oscillometric device. Arterial stiffness was measured by the baPWV, and CAC was assessed using multi-detector computed tomography. Design and method: Blood pressure was measured in both arms of 117,407 people who participated in the Kangbuk Samsung Health Study. IAD was defined as the absolute difference in systolic blood pressure in both arms and was confirmed by measuring the baPWV using an automatic oscillometric device. Arterial stiffness was measured by the baPWV, and CAC was assessed using multi-detector computed tomography. Results: The mean IAD in the overall subjects was 3.09 ± 2.83 mmHg, 6 mmHg in the 90th percentile, 8 mmHg in the 95th percentile, and 10 mmHg in the 97th percentile. In the multivariable-adjusted analysis of 92,949 subjects excluding those with a history of HTN, DM, and cardiovascular disease (CVD), increasing IAD did not statistically increase the risk of developing a CAC &gt; 0. However, IAD was associated with a baPWV of &gt; 1,400 cm/s (odds ratio [95% confidence interval], 1.23 [1.13–1.35] in the total cohort, 1.19 [1.08–1.31] in males, and 1.39 [1.11–1.73] in females). Conclusions: More than 97% of all participants had an IAD of 10 mmHg or less. IAD was significantly associated with arterial stiffness, reflecting arteriosclerosis, but not the presence of CAC, reflecting atherosclerosis. IAD may be a valuable tool for the early detection of asymptomatic, low-risk individuals with subclinical arterial disease.

Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis

Systolic inter-arm difference in blood pressure (IAD) and cognitive decline are both associated with cardiovascular disease; therefore, it was hypothesised that IAD may be predictive of cognitive decline. To examine associations of IAD with cognitive decline in a community population. A prospective study of older Italian adults enrolled in the InCHIANTI study. Univariable and multivariable associations of IAD were explored with declines in mini mental state examination (MMSE) scores, Trail Making Test A and B scores, and a composite outcome representing substantial decline in any of these scores. Backward stepwise regression was used to adjust observed associations of IAD with cognitive decline. The rate of decline for MMSE scores in 1133 participants was greater with IAD ≥5 mmHg or ≥10 mmHg. On univariable analyses continuous IAD was associated with the composite outcome (odds ratio [OR] 1.16 per 5 mmHg of IAD, 95% confidence interval [CI] = 1.02 to 1.31). Substantial decline in MMSE score was seen with IAD ≥5 mmHg (OR 1.41, 95% CI = 1.03 to 1.93), and in the composite outcome with IAD ≥5 mmHg (OR 1.44, 95% CI = 1.10 to 1.89) or ≥10 mmHg (OR 1.39, 95% CI = 1.03 to 1.88). After multivariable adjustment, an IAD ≥ 5 mmHg remained associated with reductions in the composite outcome, reflecting declining cognitive performance (OR 1.46, 95% CI = 1.05 to 2.03). An IAD ≥5 mmHg is associated with cognitive decline in a representative older population. Given that systolic inter-arm differences in blood pressure are easily measured, confirmation of these findings could inform individualised treatment for the prevention of cognitive decline and dementia.

Abnormal inter arm systolic blood pressure, inter leg systolic blood pressure and ankle brachial index (ABI) are related to vascular diseases. Our aim was to evaluate the correlation of inter arm systolic blood pressure difference (IASBPD), inter leg systolic blood pressure difference (ILSBPD), and ABI with acute aortic dissection (AAD) and their role in predicting AAD. In this prospective case-control study, 180 patients with AAD admitted to the emergency department were prospectively and consecutively collected in Tongji Hospital from October 2019 to December 2020. 180 healthy people matched by sex, age and BMI served as control group. All participants were adults over 18 years of age who underwent four-limb blood pressure measurements. IASBPD, ILSBPD and ABI were compared between the two groups and their associations with AAD were analyzed. A total of 360 patients (180 cases and 180 controls) were analyzed. In case group IASBPD was larger [(15.23 16.15) mm Hg vs. (4.19 3.63) mm Hg] and ILSBPD was larger (13.00 mm Hg vs. 5.70 mm Hg). ABI was smaller [(0.98 0.24) vs. (1.12 0.09)], and the difference was statistically significant (all p 0.05). According to the receiver operating characteristic curve (ROC), IASBPD 10 mm Hg (Sen 61.7%, Spe 88.9%), ILSBPD 13 mm Hg (Sen 50.6%, Spe 80.6%) and ABI 0.9 (Sen 53.3%, Spe 87.2%), showed significant correlation with AAD (all p 0.001). Compared with healthy people, IASBPD and ILSBPD levels were higher and ABI levels were lower in patients with AAD. IASBPD 10 mm Hg and ILSBPD 13 mm Hg can be used as indicators for early screening of AAD, and IASBPD 10 mm Hg has better predictive value for the occurrence of AAD. In patients with typical chest pain, attention needs to be paid to measuring blood pressure in the extremities.

Objective: To investigate the effects of inter-arm systolic blood pressure differences (IASBPD) on visual field progression in primary glaucoma patients with controlled intraocular pressure. Methods: In this prospective clinical study, 69 primary glaucoma patients (69 eyes) who had visited Changsha Aier Eye Hospital from August 2013 to November 2018 and who had at least 5 reliable visual reportson file were selected. According to the guided progression analysis (GPA) of the Humphrey Field Analyzer, subjects were divided into two groups, the visual field progression group and the non-progression group. All of the patients underwent multiple sets of sequential blood pressure measurements on both arms. A student t test, Fisher's exact test and logistic regression analysis were used for data analysis. Results: Thirty-four patients (34 eyes) were included in the analysis, among which 15 patients (15 eyes) were in the progression group and the other 19 patients (19 eyes) were in non-progression group. The IASBPD of the two groups was 10.6±9.0 mmHg (1 mmHg=0.133 kPa) and 5.3±2.8 mmHg, respectively, and IASBPD in the progression group was 5.26 mmHg (95% credibility interval: 0.14-10.37 mmHg) higher than that in the non-progression group (t=-2.177, P=0.045). There were no significant differences in pulse pressure, mean arterial pressure, or diastolic ocular perfusion pressure between the two groups (t=0.946, -1.118, -1.967, all P>0.05). Logistic regression analysis showed that an IASBPD of ≥10 mmHg was a risk factor for visual field progression (OR=20.310, P=0.022). Participants were also stratified into two groups with an IASBPD of <10 mmHg (n=26) and ≥10 mmHg (n=8). The rates of visual field progression for the two groups were 30.8% and 87.5%, and rates of retinal nerve fiber layer thickness progression were 42.3% and 87.5%, respectively (P=0.011, 0.030). Conclusions: Increased IASBPD may be one of the risk factors for visual field progression in primary glaucoma patients with controlled intraocular pressure. Key words: primary glaucoma; intraocular pressure; visual field; inter-arm systolic blood pressure differences

Objective: To compare the inter-arm blood pressure (BP) difference (IAD) detected from the first BP reading with that detected from the average value of 2-3 BP readings when using computer program-controlled BP measurement (CCBPM). Methods: The CCBPM was used for BP measurement during a health examination of 3，067 rural community residents. The IAD was evaluated based on the first BP reading and the average value of 2-3 BP readings, respectively. A systolic- and diastolic-IAD (sIAD or dIAD) ≥10 mm Hg was considered abnormal. Results: In the reference arm, the SBP/DBP was 136.42±19.81/81.23 ± 10.51 mm Hg in the first BP reading; while in the average reading, they were significantly lower (134.64±18.39/80.28±9.78 mm Hg, both P = 0.011). The detection rate of abnormal sIAD was 9.08% and that of abnormal dIAD was 4.74% in the first BP reading, while in the average reading, the sIAD was 5.47% and the dIAD was 2.47%. There was a difference of about 40% for sIAD. Conclusion: Even when using CCBPM, the detection rate of IAD in the first BP reading was significantly higher than that in the average value of 2-3 BP readings.

Effect of inter-arm blood pressure differences on outcomes after percutaneous coronary intervention

Background: Contrast-induced acute kidney injury (CI-AKI) can be a serious complication for patients with peripheral artery disease(PAD) undergoing peripheral vascular interventions(PVI). An interarm blood pressure difference (IABPD)≥10 mmHg has been identified as an independent risk factor for cardiovascular disease and mortality. This study aimed to evaluate the predictive value of IABPD for the risk of CI-AKI in PAD patients undergoing PVI. Materials and Methods: This prospective study included 171 consecutive patients who underwent PVI. IABPD was defined as the difference in systolic blood pressure between the two arms and was considered significant if it was≥10 mmHg. Patients were categorized into two groups based on the occurrence of CI-AKI. Results: The incidence of CI-AKI after PVI was 21 %. The CI-AKI(+) group had a significantly higher incidence of IABPD &amp;gt;10 mmHg (28% vs. 8%, p&amp;lt;0.001). Multivariable logistic regression analysis identified IABPD (OR:1.135, 95% CI:1.037-1.243, p=0.006) as an independent predictor of CI-AKI. Additionally, hypertension (OR:2.308, 95% CI:1.091-4.885, p=0.03), higher mean blood pressure (OR:1.055, 95% CI 1.001-1.111, p=0.04), lower eGFR (OR 0.963, 95% CI 0.948-0.978, p&amp;lt;0.001), higher CRP levels (OR:1.028, 95% CI:1.006-1.050, p=0.01), and lower LVEF (OR:0.969, 95% CI 0.938-0.998, p=0.04) were significant predictors of CI-AKI. Furthermore, having TASC C-D lesions compared to TASC A-B was associated with a higher risk of CI-AKI (OR:3.304, 95% CI 1.197-9.117, p=0.02). Conclusions: This study demonstrated that IABPD is significantly associated with the development of CI-AKI in patients undergoing PVI for PAD. Assessing IABPD in patients before PVI could help clinicians identify those at an elevated risk for developing CI-AKI. Keywords: Contrast-induced acute kidney injury, Interarm blood pressure difference, Peripheral artery dis-ease, Peripheral vascular intervention

Hypertension has been reported in 8-32% of HIV-infected individuals. Large interarm blood pressure differences (IABPD) may cause misclassification of blood pressure (BP) status. The objectives of this study were to determine the magnitude and factors associated with IABPD in HIV-infected women and uninfected controls. Using automated devices, two BP recordings were measured and averaged from each arm in Brooklyn enrollees of the Women's Interagency HIV Study. Absolute IABPD was calculated for each patient. Among 335 subjects, 238 were HIV infected and 97 were uninfected. Mean systolic and diastolic IABPD were 6 +/- 5 mm Hg and 4 +/- 3 mm Hg, respectively. Twenty-six percent of subjects had systolic IABPD >10 mm Hg and 6% had systolic IABPD >20 mm Hg. Fifteen percent of subjects had diastolic IABPD >10 mm Hg. Interarm BP differences were not associated with HIV serostatus, CD4(+) cell count, and use of highly active antiretroviral therapy. Systolic IABPD >20 mm Hg was associated with obesity (ORadj 5.37, 95% CI 1.47, 19.65), and LDL cholesterol above 160 (ORadj 9.12, 95% CI 2.53, 32.88). Right arm BP measurement resulted in 10% of subjects with high/uncontrolled BP. Bilateral arm BP measurement increased the yield to 15% (p < 0.001). In conclusion, systolic and diastolic IABPD are common and appear to be of clinically important magnitude. Systolic IABPD are related to cardiovascular risk factors but not to HIV-related factors. Bilateral BP determination is important to detect and manage hypertension as well as for accurate cardiovascular risk assessment.

Background: This study investigated the association of high ankle-brachial index difference (ABID) and systolic inter-ankle blood pressure difference (IAND) with short- and long-term outcomes in acute ischemic stroke patients without peripheral artery disease (PAD). Methods: Consecutive patients with acute ischemic stroke who underwent ankle-brachial index (ABI) measurement were enrolled. ABID was calculated as |right ABI-left ABI|. IAND and systolic inter-arm blood pressure difference (IAD) were calculated as |right systolic blood pressure – left systolic blood pressure|. Poor functional outcome was defined as modified Rankin Scale score ≥3 at 3 months. Major adverse cardiovascular events (MACEs) were defined as stroke recurrence, myocardial infarction, or death. Results: A total of 2901 patients were enrolled and followed up for a median of 3.1 (interquartile range, 1.6–4.7) years. Among them, 2643 (84.9%) patients did not have PAD. In the logistic regression analysis, ABID ≥ 0.15 and IAND ≥ 15 mmHg were independently associated with poor functional outcome (odds ratio (OR), 1.970, 95% confidence interval (CI), 1.175‒3.302; OR, 1.665, 95% CI, 1.188‒2.334, respectively). In Cox regression analysis, ABID ≥0.15 and IAND ≥ 15 mmHg were independently associated with MACEs (hazard ratio (HR), 1.514, 95% CI, 1.058‒2.166; HR, 1.343, 95% CI, 1.051‒1.716, respectively) and all-cause mortality (HR, 1.524, 95% CI, 1.039‒2.235; HR, 1.516, 95% CI, 1.164‒1.973, respectively) in patients without PAD. Conclusion: High ABID and IAND are associated with poor short-term outcomes, long-term MACE occurrence, and all-cause mortality in acute ischemic stroke without PAD.

Increased interarm blood pressure difference is associated with autonomic dysfunction and atherosclerosis in patients with chest pain and no history of coronary artery disease